Background: Peripheral intravenous (PIV) access is one of the most commonly performed invasive procedures in unwell patients. Although, most patients can have PIVs placed by palpation, there is a subset of patients with difficult vascular access that will require ultrasound-guided peripheral IVs. We have covered this topic before with Jacob Avila (The Ultrasound Podcast, 5 Minute Sono) in . One thing we did not cover was catheter dwell rates. Catheter dwell rate is an important endpoint as it takes time to perform the procedure, but more importantly for the patient, premature IV failure can include complications such as infiltration, phlebitis, ischemia, necrosis, as well as delays in receiving medications. Therefore, an important concept worth covering is the length of the catheter that is in the vein.
Midline catheters, which we have also covered on REBEL EM are catheters with lengths of 6 to 20cm and represent a potential solution. These catheters have high success rates and longevity, but insertion requires institutional protocols and specialized training. A nice go between is the peripheral ultralong catheter (ULC), which is 6.35cm. As with anything new in medicine, it is important to review the evidence to ensure we are performing best practices for our patients....Read More
I have been thinking a lot about patients with COVID-19 and the pulmonary pattern that they develop. This disease process has been categorized like ARDS, but the reality is it is not like "typical" ARDS. Lung compliance is often normal in these patients, and many patients are not in respiratory distress despite low O2 saturations. Patients can have a bizarre hypoxemia that does not correlate with their symptoms. I have even read reports of patients looking comfortable and speaking in full sentences with oxygen saturations in the 40 – 80% range. There are also more traditional patients in respiratory distress with similar oxygen saturations. This is a situation where we cannot treat a patient based solely on a number - pulse oximetry may not be a reliable marker of respiratory compromise.
Approaches to oxygen supplementation have stressed minimizing aerosolization of viral particles by avoiding HFNC and NIV. This appears to be a fear-based statement as opposed to an evidence based one. If we go straight from nasal cannula to intubation, we will simply run out of ventilators. Then, more challenges present themselves like rationing mechanical ventilation and trying to figure out how to split ventilators due to the lack of resources.
Finally, I have yet to find a study that shows a mortality rate <50% once a patient is intubated. Maybe a better way to deal with these patients is an intermediary step using HFNC or CPAP while proning patients while they are awake, before considering intubation. In this post, I want to review some evidence to support my thoughts on this and, just assume that in every scenario we are discussing full PPE (eye protection, N95/PAPR, gown, gloves, and face shield)....Read More